Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Oaks Care during CMS and state inspections, most recent first.
A resident with recurrent UTIs and hematuria had a physician’s order for a urology consult, but facility staff did not complete or document the referral. During interviews and record reviews, the DON and ICP confirmed the existence of the order and the absence of any documentation that a urology referral was made, indicating the order may have been missed. This was not consistent with the facility’s policy requiring timely submission of physician-ordered services, resulting in the resident not being evaluated by a urologist and creating the potential for untreated urinary tract disease.
Failure to provide hand hygiene before meals affected five residents. A CNA handed one resident her lunch tray without cleaning her hands and acknowledged the omission, and four other residents stated staff also did not clean their hands before serving lunch. One resident used tissue paper from her bedside table to wipe her hands, another said she sometimes gets a washcloth or wipe but not that day, and the facility P&P for serving meals states hands and face should be clean.
The facility failed to develop and document complete care plans for two residents with identified needs. One resident was on 1:1 monitoring, but staff gave differing reasons for the monitoring and the care plan had no goals or interventions for it. Another resident was admitted to hospice care, but the DON could not find a documented hospice/end-of-life care plan in the EMR.
Accurate documentation was not maintained for a resident returning from HD, as the post-dialysis monitoring record showed an incorrect return time and the LVN stated she did not complete the VS or assessment. For another resident, the O2 concentrator was observed set at 3 L even though the order was for 2 L/min via NC continuously. In addition, an emergency dialysis kit was not found at the bedside of a resident receiving HD, despite an order requiring the kit every shift.
A resident who returned from hemodialysis did not receive a post-dialysis assessment or vital signs check after arriving back at the facility. Staff observed the resident return by transport and go to her room, but no nurse or CNA entered to assess her, check the dialysis access site, or obtain VS. An LVN acknowledged the resident should have been assessed immediately, and the RN and DON stated post-dialysis assessment should include VS, pain, distress, and access-site checks.
A facility failed to keep medications and chemical cleaning/disinfecting agents separated in one of two med carts. During observation, an LPN was seen opening a med cart drawer that contained opened containers of Sani disinfectant wipes and Sani bleach wipes mixed with medication bubble packets. The LPN stated the wipes and medications should be stored separately, and the facility policy required cleaning supplies and disinfectants to be stored in an area separate from medications.
Cook Failed to Wear Required Beard Cover While Serving Food. A cook with a full beard was observed serving food without a beard cover. The cook acknowledged he should have worn one, and the CDM stated that all kitchen staff with beards are expected to wear beard covers. The facility's DRESS CODE policy required beard nets or face covers if applicable.
A LVN worked 22 days without a current license, as confirmed by the DON and employee records. The LVN's job description required a current unrestricted license, but the facility failed to ensure this qualification was met.
A resident with a history of anxiety and aggression repeatedly refused prescribed Buspirone, but the attending physician was not notified as required by facility policy. This lack of notification coincided with an incident where the resident physically injured another resident, and staff confirmed the resident's ongoing behavioral issues and need for close supervision.
A resident experienced a significant change in condition, including gurgling throat sounds, burning sensation during urination, increased confusion, and throat pain. While the physician was notified and new orders were given, there was no documentation that the responsible party was informed, as required by facility policy. The ADON confirmed the omission during record review.
A resident experienced multiple episodes of significantly elevated blood glucose over several days, but nursing staff failed to notify the physician as required by orders and facility policy. This lack of notification and documentation led to the resident being hospitalized with severe hyperglycemia, dehydration, and hypernatremia.
A facility failed to implement a care plan requiring 1:1 supervision for a resident with aggressive behavior. The resident was left alone in their room without supervision, contrary to the care plan and facility policy. The assigned Nursing Assistant did not arrange for coverage during her break, leading to the lapse in supervision.
The facility failed to implement an effective QAPI program as required by its policy. The last QAPI meeting was held in September 2024, and the plan lacked measurable data and goals. The Administrator admitted to not having analytical data for Process Improvement Projects, and the QAPI reports did not include measurable data for monthly monitoring and evaluation.
The facility failed to ensure call lights were within reach for five residents, potentially delaying care. Observations revealed call lights on the floor for residents requiring substantial assistance, contrary to facility policy.
The facility failed to complete Advance Directive Acknowledgement forms for ten residents, with no documentation showing they were informed of their rights to formulate an AD. Interviews revealed that residents and family members were not provided with necessary information, despite the facility's policy requiring it.
A GVN administered narcotics without supervision, using the ADON's EPHI access, leading to unauthorized access and potential record falsification. Additionally, wound care treatments for three residents were not documented, indicating non-compliance with physician orders.
The facility failed to maintain RNA program orders for three residents, leading to potential avoidable reductions in their range of motion. One resident with contractures and impaired mobility did not have orders for passive range of motion exercises, while another with joint mobility issues lacked orders for assisted exercises. Additionally, a resident with hand contractures did not have palm protectors applied as required. The facility did not adhere to its policy on providing appropriate services for residents with limited mobility.
The facility failed to complete performance evaluations for two CNAs and an LVN, as competency checklists were missing or outdated. CNA 3 and LVN 1 lacked completed checklists before working independently, and CNA 5's checklist was overdue. The facility could not provide their staff competency policy when requested.
The facility failed to complete quarterly social services assessments for nine residents, with some assessments overdue by up to 16 months. This oversight was acknowledged by the Social Services Supervisor and was contrary to the facility's policy, potentially delaying necessary social services for the residents.
The facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR) in July 2024, potentially leading to adverse health outcomes for residents. A review revealed 99 unaddressed pharmacy recommendations with no physician notification, and 55 recommendations lacking a final response. The DON admitted to not verifying the completion of these recommendations, contrary to the facility's policy requiring action on all recommendations.
The facility failed to properly label and store medications, leading to potential contamination and unauthorized access. Two opened medication bottles lacked open date labels, and a resident's medications were improperly stored in a cart. Additionally, 50 OTC medication bottles were accessible to unauthorized personnel, and a resident's medication was stored at the bedside without evaluation. These actions violated the facility's policies on medication safety.
The facility failed to implement proper infection control practices, including inadequately covered linen carts, staff not following enhanced droplet and contact precautions, a resident's room not being deep cleaned before another resident moved in, and a nurse not performing hand hygiene after glove removal. These lapses had the potential to transmit infectious diseases.
The facility failed to store chemical containers properly in the laundry room, with five chemical containers and a bleach bottle found on the ground. The Laundry Personnel acknowledged the containers should be stored above ground, and the Administrator confirmed that items should be at least four inches off the ground. The facility's policy on chemical storage was not provided upon request.
A resident was found to have items in their room that belonged to another resident, causing discomfort and confusion. A CNA confirmed that the items belonged to a different resident who had moved rooms. The facility's policy on maintaining a homelike environment was not followed, as it emphasizes the use of personal belongings and personalized room arrangements.
The facility failed to notify the Long Term Care Ombudsman of the transfer and discharge of two residents, as required by policy. For both residents, there was no fax confirmation that the ombudsman received the notice, and the Social Services Supervisor was unsure if the notifications were sent. The facility's policy mandates maintaining evidence of such notifications, which was not followed.
A facility failed to implement necessary interventions to prevent skin breakdown for a resident at high risk of pressure ulcers. The resident's heels were not elevated as required, despite having non-blanchable redness on the left heel. The resident's care plan and Order Summary Report indicated the need for a 'heels up' device, which was not properly utilized. The resident had a high-risk Braden Scale score and required total assistance with bed mobility, highlighting the need for adherence to the facility's pressure ulcer prevention policy.
A facility failed to follow its medication reordering and unavailable medication policies, resulting in a resident missing doses of critical diabetic medications. The licensed nurse did not reorder medications timely, notify the physician, or obtain alternative orders, leading to missed doses of Admelog, Jardiance, Lasix, and Tresiba. Interviews revealed that the facility's policy required medications to be reordered when six or fewer doses remained, and the physician should have been notified of missed doses, which was not done.
A facility failed to follow a physician's order for a resident requiring nectar thick consistency beverages, risking a choking incident. Observations revealed the resident had unthickened juice and soda, contrary to the order. The care plan did not address the resident's noncompliance, and the facility's policy on using commercially-prepared thickened liquids was not followed.
A resident, who was cognitively intact, expressed dissatisfaction with a meal that included brussels sprouts, which he disliked. Despite having specified his vegetable preferences, the facility failed to provide an alternative meal, contrary to their policy. This oversight had the potential to result in unmet nutritional needs.
The facility failed to serve food at the proper temperature for two residents, resulting in meals being served at unappetizing temperatures. Observations revealed that one resident received lukewarm breakfast items, while another reported cold food. Temperature checks showed that the food items did not meet the facility's policy requirements for hot and cold food temperatures.
The facility failed to ensure that four CNAs wore name tags, leading to residents and visitors being unable to identify staff. Observations and interviews revealed that CNAs either misplaced, forgot, or lost their name tags, contrary to the facility's policy requiring visible identification badges during work hours.
A facility failed to implement its abuse policy when an LVN did not report abuse allegations involving two residents to management. The LVN was informed by a resident that a CNA had allegedly been abusive, but did not report it, assuming the DON was already informed. Interviews with the ADON and Administrator confirmed that staff must report abuse allegations immediately. The facility's policy requires reporting within two hours if abuse is involved.
The facility failed to notify the Physician and Responsible Party (RP) of a resident's injury after a fall. The resident returned from the emergency room with abrasions to bilateral shins, but there was no evidence of notification to the Physician and RP. The Director of Nursing confirmed this oversight, which is against the facility's policy requiring notification of changes, including accidents resulting in injury.
A resident's call light was found to be non-functional, which could prevent staff from being aware of the resident's need for assistance. The issue was confirmed by a CNA and the Maintenance Director, and it was noted that the facility's policy requires call lights to be functional at all times.
The facility failed to ensure that monitoring and wound care were completed as ordered by the physician for two residents. Documentation indicated that monitoring and treatments were missed on multiple occasions, which was confirmed by the Treatment Nurse and the Director of Nursing.
A resident was not administered Bumetanide, a vital medication for congestive heart failure, for three consecutive days due to awaiting pharmacy refill and pending delivery. The facility failed to notify the physician of this lapse, as required by their policy. The DON confirmed the lack of documentation regarding physician notification.
A facility failed to document the administration of medications for a resident, resulting in an inaccurate MAR. The resident was receiving treatment for various conditions, including irregular heart rate and hypertension. The DON confirmed that medications were administered but not recorded, contrary to the facility's policy.
The facility failed to develop a baseline care plan for a resident admitted with a partial thickness wound to the coccyx area. The DON confirmed the absence of documented evidence for the required care plan within 48 hours of admission, as per facility policy.
The facility failed to provide wound care as ordered for a resident, as documented in the Treatment Administration Record. The Director of Nurses confirmed the lapse in care, which was not in accordance with the facility's wound treatment management policy.
Failure to Complete Physician-Ordered Urology Referral for Resident With Hematuria
Penalty
Summary
The facility failed to ensure services met professional standards of quality when staff did not carry out a physician’s order for a urology referral for Resident 1. A physician’s order dated 5/12/25 directed that Resident 1 be referred to urology for evaluation of hematuria (blood in the urine). During interview and concurrent record review on 3/12/26, the DON confirmed that Resident 1 had this order but there was no documented evidence that the urology referral had been made, and acknowledged the referral should have been completed. In a separate interview, the Infection Control Preventionist stated that Resident 1 had recurrent UTIs and that the physician had ordered a urology consult on 5/12/25, but upon reviewing the clinical record was also unable to find documentation that the referral was initiated, stating the order might have been missed. Review of the facility’s policy “Provision of Physician Ordered Services” indicated that qualified nursing personnel are required to submit timely requests for physician-ordered services, including consultations, to the appropriate entity, which was not followed in this case. This failure resulted in Resident 1 not being seen by a urologist and created the potential for untreated urinary tract disease, as noted in the report.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to implement effective infection control practices when staff did not provide hand hygiene before meals for five sampled residents. During a concurrent observation and interview, a CNA handed one resident her lunch tray in the hallway outside her room and stated she had not provided hand hygiene and should have done so. The resident stated she was not given hand hygiene before receiving lunch and said she would have liked for her hands to be cleaned. Her BIMS score was 11. Additional observations and interviews showed the same issue for four other residents during lunch. One resident stated staff did not provide hand hygiene before serving her meal and said she sometimes receives a washcloth or wipe but not that day. Another resident, who was eating using her hands, stated staff did not provide hand hygiene before the meal and that she used tissue paper from her bedside table to wipe her hands. A third resident stated staff did not provide hand hygiene before serving lunch and that she sometimes asks for assistance. A fourth resident stated staff did not provide hand hygiene before serving her salad and said a wipe is sometimes included on the meal tray. The facility policy titled "Serving a Meal" stated to make sure hands and face are clean.
Incomplete care plans for monitoring and hospice needs
Penalty
Summary
The facility failed to follow its Comprehensive Care Plans policy for two sampled residents by not developing or documenting complete care plans for all identified needs. Resident 31 was observed on one-to-one monitoring in the room, but the LVN stated she did not know the reason for the monitoring. A CNA stated the resident was being monitored for falls and that one-to-one monitoring had started about a month earlier. During record review, Resident 31’s care plan contained no goals or interventions for one-to-one monitoring, and the DON stated the monitoring was for behaviors and should have been care planned. The resident’s order summary indicated one-to-one monitoring every shift. Resident 101’s order summary indicated hospice care effective 2/7/26, with instructions to admit the resident to the hospice care agency with any change in condition or medication refill. During review of the electronic medical record, the DON was unable to provide documented evidence of a hospice/end-of-life care plan and stated the resident had been picked up for hospice care and that a hospice care plan should have been implemented. The facility policy required a comprehensive, person-centered care plan for each resident with measurable objectives and timeframes to meet medical, nursing, psychosocial, and functional needs, and the record review showed that this was not documented for these two residents.
Documentation, oxygen therapy, and dialysis emergency kit deficiencies
Penalty
Summary
Accurate documentation was not maintained for a resident returning from hemodialysis. During an observation, the resident arrived by medical transport and was placed in a wheelchair next to the nurse's station. From 3:12 p.m. to 3:41 p.m., no staff entered the resident's room to assess the resident or obtain vital signs. The resident's Nurses Dialysis Communication Record for that day documented that the resident returned to the unit at 2:20 p.m., but the DON stated this time was incorrect because the resident did not return until 3:09 p.m. The DON later stated an LVN had accidentally charted the post-dialysis monitoring at the wrong time, and the LVN stated she did not take the resident's vital signs or complete the assessment on that date. Physician's orders for oxygen administration were not followed for another resident. During observation, the resident was in bed with nasal cannula tubing in place and stated she was receiving 2 liters of oxygen. The oxygen concentrator at the bedside was observed set at 3 liters, and an LVN confirmed the concentrator had been running at 3 liters. The resident's order summary directed oxygen at 2 L/min via nasal cannula continuously and to monitor oxygen saturation every shift, with a goal to maintain oxygen saturation greater than 90%. An emergency dialysis kit was not available at the bedside for a resident receiving hemodialysis. During observation, an LVN could not locate the kit in the resident's room, and another LVN also did not see the kit hanging above either bed area after the resident had been moved from one bed to another. The resident's order summary required an emergency kit at the bedside every shift and listed the contents as gloves, gauze, tape, a tourniquet, and a clamp.
Missed Post-Dialysis Assessment
Penalty
Summary
The facility failed to ensure that a resident who received hemodialysis had a post-dialysis assessment after returning from the dialysis center. The resident’s order summary indicated dialysis every Monday, Wednesday, and Friday. On the day of the event, the resident returned to the facility by medical transport in a wheelchair, placed a dialysis communication binder on the nurse’s station counter, and then went to her room. From the time she returned until later that afternoon, no staff entered the room to assess her or obtain vital signs. CNA 1 stated she had not obtained the resident’s vital signs after the resident returned from dialysis, and LVN 3 stated he was aware the resident had returned but had not completed the post-dialysis assessment. RN 1 stated residents returning from dialysis should be assessed and have vital signs obtained upon arrival back to the facility, including monitoring for pain, distress, and checking the dialysis access site for an intact dressing and bleeding. DON 1 stated it was her expectation that the nurse would assess the dialysis access site, assess for pain, and obtain vital signs as soon as the resident returned. The facility policy for hemodialysis catheter access and care stated that care immediately following dialysis includes documentation of post-dialysis observations and action if there is major bleeding from the site.
Medications and Disinfectants Stored Together in Medication Cart
Penalty
Summary
The facility failed to ensure medications and chemical cleaning/disinfecting agents were stored separately in one of two medication carts. During a concurrent observation and interview on 2/11/26 at 8:26 a.m. with LVN 2, the bottom right drawer of the 300 medication cart was observed divided into three sections. One section contained an opened/used container of Sani disinfectant wipes and 11 medication bubble packets, another section contained an opened/used container of Sani wipes bleach, and the third section contained 12 medication bubble packets. LVN 2 stated the Sani wipes containers should be stored on one side and the medication should be stored on the other side, and that they should not be stored together. The facility policy titled Medication Storage stated that potentially harmful substances such as cleaning supplies and disinfectants are to be stored in an area separate from medications.
Cook Failed to Wear Required Beard Cover While Serving Food
Penalty
Summary
The facility failed to ensure that one of two cooks followed the DRESS CODE policy and procedures when Cook 2, who had a full beard, was observed serving food without a beard cover. During the observation in the kitchen, Cook 2 was not wearing a beard cover while actively serving food. When interviewed, Cook 2 stated he should have worn a beard cover. The Certified Dietary Manager stated that all kitchen staff with beards are expected to wear beard covers. Review of the facility's DRESS CODE policy dated 2023 showed that beard nets or face covers are required if applicable.
Unlicensed LVN Provided Resident Care
Penalty
Summary
The facility failed to ensure that one of four sampled Licensed Vocational Nurses (LVN) was qualified to provide resident care, as the LVN worked without a current license. Review of the LVN's employee file showed that their license had expired, yet the work schedule indicated the LVN continued to work for 22 days after the expiration. The Director of Nurses (DON) confirmed that the LVN worked these days without a valid license and acknowledged that the LVN should not have been working without a current license. The facility's job description for Charge Nurse, which the LVN had signed, required a current unrestricted license as a Registered Nurse (RN) or LVN in the practicing state.
Failure to Notify Physician of Repeated Medication Refusals Leading to Resident Altercation
Penalty
Summary
The facility failed to follow its own policy and procedure regarding physician notification for a resident who repeatedly refused an ordered medication. Specifically, a resident with a physician's order for Buspirone to manage anxiety and unprovoked physical aggression refused the medication multiple times over several months, with documented refusals ranging from 55 to 57 times per month. Despite the facility's policy requiring the attending physician to be notified after two or more consecutive refusals, there was no documented evidence that the physician was informed of these refusals. As a result of the ongoing medication refusals, the resident exhibited aggressive behavior, including a physical altercation in which the resident grabbed another resident's arm, causing a skin tear and bleeding. Staff interviews confirmed the resident's history of aggressive behavior and the need for a one-on-one sitter. The Director of Nursing reviewed the records and confirmed that the policy for physician notification was not followed.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party when there was a change in condition for one of the sampled residents. Specifically, a resident experienced gurgling sounds in the throat, burning sensation during urination, increased confusion, and throat pain. The physician was notified and provided orders for suction as needed, a speech therapy evaluation, and increased fluids. However, there was no documentation that the resident's responsible party was informed of these changes. During an interview and record review, the Assistant Director of Nursing confirmed that the responsible party was not notified, which was contrary to the facility's policy requiring notification of a resident's representative in the event of a significant change in the resident's status.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition as required by physician orders and facility policy. Specifically, the resident had multiple blood glucose readings significantly above the ordered threshold of 200 mg/dL over several consecutive days. Despite the physician order to notify for blood sugars greater than 200 mg/dL, there was no documentation that the physician was informed of these elevated results. Interviews with nursing staff confirmed that notifications were either not made or not documented, and one nurse was unaware of the notification requirement in the physician's order. The Director of Nursing also confirmed the lack of documentation and acknowledged that the physician should have been notified immediately when the resident's blood sugar exceeded the specified limit. As a result of the failure to notify the physician, the resident experienced a significant decline, presenting with symptoms such as a deep chest cough, elevated pulse, and high fever, which led to a transfer to the hospital. Upon admission, the resident was diagnosed with severe hyperglycemia, dehydration, and hypernatremia, with critical lab values indicating a life-threatening condition. The facility's own policies required staff to incorporate physician notification parameters into care planning and to notify the physician of changes in the resident's condition, but these procedures were not followed in this case.
Failure to Implement 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to implement a care plan for a resident who was known to exhibit physically aggressive behavior. The care plan, dated December 16, 2024, required the resident to have 1:1 supervision at all times due to their aggressive tendencies. However, on January 29, 2025, the resident was observed alone in their room without supervision. The Director of Nursing confirmed that the resident should have been under constant supervision. The Nursing Assistant assigned to the resident admitted to leaving the resident alone without arranging for another staff member to cover during her break. This lapse in supervision was contrary to the facility's policy and procedure for comprehensive, person-centered care plans, which emphasize the importance of implementing interventions to maintain the resident's well-being.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to adhere to its Quality Assurance and Performance Improvement (QAPI) policy and procedure, which is a data-driven, proactive approach to improving the quality of care and services. During an interview and record review, it was found that the last QAPI meeting was held in September 2024, and the QAPI plan was not effective. The Administrator admitted that there was no measurable data discussed for completing nursing staff competencies, and the analytical data was not available for Process Improvement Projects (PIPs). The QAPI reports lacked measurable data that were being monitored and evaluated monthly, and the QAPI goals were not measurable. The facility's policy and procedure on QAPI, dated February 2020, required the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. Key components included tracking and measuring performance, establishing goals and thresholds for performance measurement, and systematically analyzing the underlying cause of systemic quality deficiencies. However, the facility did not follow these procedures, as the QAPI committee did not meet monthly to review reports, evaluate data, and monitor QAPI-related activities, leading to the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for five of the 18 sampled residents, which could potentially delay care and assistance. During observations and interviews, it was noted that the call lights for Residents 33, 50, 64, 67, and 63 were found on the floor, out of reach. Certified Nursing Assistant (CNA) 3 observed Resident 33's call light on the floor and stated it should have been clipped to the resident's blanket. Resident 33's Minimum Data Set (MDS) indicated severe cognitive impairment and required maximal assistance for upper body dressing and mobility, with a care plan intervention to keep the call bell within reach. Similarly, Resident 50's call light was found on the floor during an observation with a Restorative Nurse Assistant (RNA), who confirmed it should have been within reach. Residents 64 and 67 also had their call lights on the floor, and both required substantial to total assistance with self-care and mobility. Resident 63, who had moderate cognitive impairment and required substantial assistance, was unable to find the call light, which was also on the floor. The facility's policy stated that staff should ensure call lights are within reach and secured, but this was not adhered to in these cases.
Failure to Complete Advance Directive Acknowledgement Forms
Penalty
Summary
The facility failed to ensure that an Advance Directive Acknowledgement (ADA) form was completed for ten out of twenty sampled residents. During interviews and record reviews, it was found that residents had not completed an Advance Directive (AD), and there was no documentation to show that they were offered or received information about their right to formulate an AD. This was observed in multiple cases, including Resident 443, Resident 40, and Resident 20, among others. The Admission Coordinator (AC) confirmed that the ADA forms were incomplete and that there was no evidence of information being provided to the residents regarding ADs. Further interviews revealed that Resident 18, who had a moderate cognitive impairment with a BIMS score of 12, did not remember being provided information on ADs and expressed a desire for more information. The Social Services Supervisor (SSS) also confirmed the lack of documentation for Resident 18. Additionally, a family member of Resident 18 stated that neither they nor the resident were provided information on the right to formulate an AD. Similar findings were noted for other residents, such as Resident 6, Resident 37, and Resident 51, where the ADA forms were incomplete, and there was no documentation of information being provided. The facility's policy and procedure on Advance Directives, dated September 2022, indicated that residents have the right to formulate an AD and should be provided with written information about their rights. However, the facility failed to adhere to this policy, as evidenced by the incomplete ADA forms and lack of documentation for the residents involved. This failure had the potential to result in the residents' wishes or health choices not being honored.
Unauthorized Medication Administration and Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to ensure proper supervision and adherence to professional standards of quality in medication administration and documentation. A Graduate Vocational Nurse (GVN), who was unlicensed, was found administering narcotics to residents without the supervision of a licensed nurse. This occurred for three residents, where the GVN used the Assistant Director of Nursing's (ADON) electronic protected health information (EPHI) access code to document medication administration, including controlled substances like Morphine Sulfate and Oxycodone HCL. The ADON confirmed that the GVN was not authorized to dispense or sign off on controlled medications independently, and the GVN's actions resulted in unauthorized access to residents' protected health information and potential falsification of medical records. Additionally, the facility failed to follow physician orders regarding wound care treatment documentation for three residents. The Treatment Administration Records (TAR) for these residents were missing licensed nurse initials, indicating that the required wound care treatments were not documented as completed. The Director of Nursing (DON) confirmed that the absence of initials meant the treatments were not performed. The facility's policies and procedures required that treatments be documented on the TAR or in the electronic health record, which was not adhered to in these instances.
Failure to Maintain RNA Program Orders for Residents
Penalty
Summary
The facility failed to ensure that three residents had appropriate Restorative Nurse Assistant (RNA) program orders, which are essential for maintaining or improving their range of motion. Resident 47, who has contractures and impaired functional range of motion due to hemiplegia and hemiparesis, did not have RNA program orders for passive range of motion exercises. Similarly, Resident 48, who has impaired joint mobility and decreased ability to perform activities of daily living independently, lacked RNA program orders for active assisted range of motion exercises. Both residents' care plans indicated the need for these interventions, but the orders were not renewed as required. Additionally, Resident 51, who has functional limitations in the range of motion of both upper extremities and contractures in both hands, did not have palm protectors applied as per the RNA order. The order for palm protectors, which was intended to protect the skin integrity and prevent pressure wounds, was not renewed after it was completed in August 2024. The facility's policy on resident mobility and range of motion, which mandates appropriate services and equipment for residents with limited mobility, was not adhered to in these cases.
Failure to Complete Staff Competency Evaluations
Penalty
Summary
The facility failed to complete performance evaluations for three out of eight sampled employees, which included two Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN). During interviews and record reviews, it was found that CNA 3 and LVN 1 did not have their competency checklists completed prior to working on the floor alone, despite being hired on 8/1/24 and 7/1/24, respectively. The Director of Staff Development (DSD) confirmed the absence of these checklists and acknowledged that they should have been completed before the employees began working independently. Additionally, CNA 5's most recent competency checklist was completed on 7/7/23, and the DSD admitted that CNA 5 was due for an annual review and competency checklist in July of the current year, which had not been completed. The Assistant Director of Nursing (ADON) also confirmed that LVN 1 did not have a competency checklist completed upon hire. The facility was unable to provide their policy and procedure on staff competency when requested, further highlighting the deficiency in ensuring staff competencies were evaluated and documented as required.
Failure to Complete Quarterly Social Services Assessments
Penalty
Summary
The facility failed to ensure that social services assessments (SSA) were completed quarterly for nine of the 19 sampled residents. This deficiency was identified during an interview and record review with the Social Services Supervisor (SSS), where it was found that the SSAs for several residents were significantly overdue. Specifically, Resident 51's SSA was 11 months overdue, Resident 63's was 15 months overdue, Resident 71's was 11 months overdue, Resident 44's was 13 months overdue, Resident 27's was 15 months overdue, Resident 6's was 13 months overdue, Resident 54's was 6 months overdue, Resident 47's was 16 months overdue, and Resident 48's was 16 months overdue. The facility's job description for Social Services, dated December 5, 2012, and the policy and procedure titled 'Social Services,' dated February 2023, both indicated that SSAs should be completed on a quarterly basis. The SSS acknowledged that the assessments should have been conducted every three months, as per the facility's guidelines. This failure to conduct timely assessments had the potential to delay the provision of medically related social services, thereby affecting the psychosocial needs of the residents.
Failure to Act on Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR) for the month of July 2024, which had the potential for residents' adverse health outcomes due to the physician not being notified of the pharmacy recommendations. During a review of the facility's Psychotropic & Sedative/Hypnotic Utilization by Resident (PSHUR) for July 2024, it was found that there were 99 pharmacy recommendations that the facility did not act on, with no documentation of physician notification. The Director of Nursing (DON) confirmed that the July 2024 pharmacy recommendations were not acted upon and admitted to not checking if they were completed. Additionally, a review of the Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking a Final Response (CPMRRARLFR) for the same period indicated that there were 55 pharmacy recommendations not acted on. The DON stated that the Assistant Director of Nursing (ADON) did not complete the CPMRRARLFR in July 2024 and acknowledged not verifying its completion. The facility's policy and procedure on Medication Regimen Review required staff to act upon all recommendations according to the procedures for addressing medication regimen review irregularities.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. Two opened medication bottles in the medication storage room were not labeled with an opened date, which could lead to potential contamination. Additionally, three bottles of medications for a resident were found in a plastic bag in a medication cart drawer, despite the resident's current medications being stored elsewhere. This oversight could result in the administration of discontinued or outdated medications. Furthermore, approximately 50 over-the-counter medication bottles were not securely stored, allowing unauthorized personnel access, and a resident's medications were not safely stored, posing a risk of access by unauthorized staff and residents. During observations, it was noted that the facility's policies and procedures were not followed. The Assistant Director of Nursing acknowledged the lack of open date labels on medication bottles and the improper storage of a resident's medications. The Director of Nursing confirmed that non-nursing staff had access to a storage room containing medications, and a Licensed Vocational Nurse identified a resident's medication stored at the bedside without a self-medication evaluation. These findings indicate a failure to adhere to the facility's policies on medication labeling, storage, and self-administration, potentially compromising medication safety and security.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. One of the clean linen carts was observed to be inadequately covered during transport, with a five-inch opening due to an ill-fitting cover. This was acknowledged by the laundry personnel and the infection preventionist, who confirmed that the linen cart should have been entirely covered as per the facility's policy. Additionally, four staff members, including CNAs and a nursing consultant, did not adhere to enhanced droplet and contact precautions. This included failing to change N95 masks after exiting isolation rooms and neglecting to wear appropriate personal protective equipment (PPE) such as gowns, face shields, and gloves when entering rooms with posted precautionary signs. Furthermore, a resident's room was not deep cleaned before another resident moved in, leaving personal items from the previous occupant, which was confirmed by the housekeeper and infection preventionist. The housekeeper stated that deep cleaning was contingent on the removal of personal belongings, which had not been done. Lastly, a licensed vocational nurse failed to perform hand hygiene after removing gloves and before handling clean supplies in a resident's room, contrary to the facility's hand hygiene policy. These lapses in infection control practices had the potential to transmit infectious diseases within the facility.
Improper Chemical Storage in Laundry Room
Penalty
Summary
The facility failed to properly store chemical containers in the laundry room, which posed a potential risk to the health and safety of staff and residents. During an observation and interview, it was noted that five chemical containers and one bleach bottle were placed on the ground next to the washing machine. The Laundry Personnel acknowledged that these containers were filled with chemicals and should have been stored above ground. The Administrator confirmed that nothing should be on the ground in the laundry room and that all items should be stored at least four inches off the ground. Despite requests, the facility's policy and procedure on chemical storage were not provided.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a homelike environment for one of its residents, identified as Resident 87. During an observation and interview, it was noted that a breathing exercise device labeled with another resident's initials was hanging on the wall in Resident 87's room. Resident 87 expressed discomfort and confusion about the presence of items that did not belong to him. A Certified Nursing Assistant (CNA) confirmed that the belongings in Resident 87's room belonged to a different resident, Resident 77, who had already moved to another room. The facility's policy on maintaining a homelike environment emphasizes the importance of residents using their personal belongings and having personalized room arrangements, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure timely notification to the Long Term Care Ombudsman regarding the transfer and discharge of two residents, Resident 89 and Resident 90. For Resident 89, the Transfer or Discharge Fax Cover Sheet Ombudsman Program (TDFCSO) dated 8/2/24 indicated a discharge, but there was no fax confirmation that the ombudsman received the notice. During an interview, the Social Services Supervisor (SSS) admitted uncertainty about whether the notification was received, as there was no fax confirmation. Similarly, for Resident 90, the TDFCSO dated 9/2/24 also lacked fax confirmation of receipt by the ombudsman. The SSS acknowledged that the discharge notification should have been completed within 30 days of discharge, but there was no evidence of the fax being sent. The facility's policy and procedure on transfer and discharge required maintaining evidence that the notice was sent to the Ombudsman, which was not adhered to in these cases.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement interventions to prevent skin breakdown for a resident, identified as Resident 51, who was at high risk for developing pressure ulcers. During an observation and interview, it was noted that Resident 51's heels were not elevated and were touching the bed, despite having non-blanchable redness on the left heel, which can indicate a pressure ulcer. The Licensed Vocational Nurse (LVN) confirmed that the resident's heels were supposed to be elevated to prevent skin breakdown. The resident's Order Summary Report indicated the use of a 'heels up' device to monitor for proper placement every shift due to a history of blanchable redness. The resident's Braden Scale score was 12, indicating a high risk for skin breakdown, and the care plan specified the need for a 'heels up' device to protect the skin while in bed. Additionally, the Minimum Data Set (MDS) noted that the resident had limited range of motion in both lower extremities and required total assistance with bed mobility. The facility's policy on pressure ulcers required documentation and reporting of current treatments, including support surfaces, which was not adhered to in this case.
Failure to Reorder and Notify of Unavailable Medications
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding medication reordering and handling unavailable medications, resulting in a deficiency. A licensed nurse did not reorder medications in a timely manner, failed to notify the physician of unavailable medications, and did not obtain alternative orders for a resident. This led to the resident not receiving physician-ordered diabetic medications, which are crucial for managing blood sugar levels. The resident missed doses of several medications, including Admelog, Jardiance, Lasix, and Tresiba, due to the medications not being available from the pharmacy. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that medications should have been reordered at least seven days before running out, and the physician should have been notified of missed doses. The facility's policy required immediate action when medications were unavailable, including notifying the physician and obtaining alternative treatment orders. However, there was no documentation of physician notification or pharmacy contact regarding the missed medications. The facility's policy also stated that medications should be reordered when six or fewer doses remain, which was not followed in this case.
Failure to Follow Physician's Order for Thickened Liquids
Penalty
Summary
The facility failed to adhere to the physician's order for a resident requiring nectar thick consistency beverages, which could potentially lead to a choking incident. During an observation, it was noted that the resident had unthickened juice on their bedside table, and a CNA confirmed that the resident consumed thin liquids, despite the order for nectar thick consistency. Additionally, the Certified Dietary Manager was unaware if the resident's soda was being thickened as required. The resident's Order Summary Report indicated a diet order of regular diet puree texture with nectar thick consistency, but the care plan did not address the resident's noncompliance with the diet order. Interviews with the DON and another CNA revealed that the thickener was available at the nurses' station, but the care plan for the resident's risk for dehydration did not specify the need for nectar thick liquids. The facility's policy stated that only commercially-prepared thickened liquids should be used, but this was not followed in the resident's case.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which had the potential to result in unmet nutritional needs. During an observation and interview, the resident expressed dissatisfaction with the meal provided, which included brussels sprouts, mashed potatoes and gravy, and pot roast. The resident, who was cognitively intact with a BIMS score of 13, stated a dislike for brussels sprouts and indicated that once they were on his plate, he would not eat the meal. The resident could not recall what he had ordered but was certain he did not request brussels sprouts. A review of the resident's meal ticket and nutrition evaluation revealed that the resident had specified dislikes for certain vegetables, preferring only corn, peas, and green beans. The facility's policy and procedure for food substitutions indicated that residents should be offered a suitable nourishing alternate meal if they refuse the planned meal. However, this policy was not followed, as the resident was not provided with an alternative meal after expressing his refusal to eat the brussels sprouts.
Improper Food Temperature for Residents
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature for two residents, resulting in meals being served at unappetizing temperatures. During observations and interviews, it was noted that one resident received a breakfast tray with lukewarm waffle, toast, and sausage patty. Another resident reported that her breakfast, including French toast, oatmeal, and sausage, was cold, with a specific complaint about the oatmeal always being cold. A subsequent temperature check of the food items revealed that the sausage patty was at 108.6°F, French toast at 101.3°F, milk at 59.8°F, and cranberry juice at 61.6°F. According to the Dietary Supervisor, the milk should have been at least 45°F, and the waffle, French toast, and sausage should have been at least 120°F. The facility's policy indicated that hot entrees should be greater than 120°F and milk or cold beverages should be less than 45°F.
Failure to Ensure Staff Wear Name Tags
Penalty
Summary
The facility failed to ensure that four out of five sampled Certified Nursing Assistants (CNAs) were wearing name tags, which resulted in residents and visitors being unable to identify the staff providing care. This deficiency was identified through observations, interviews, and record reviews. Family Member 1 expressed difficulty in identifying staff due to the absence of name tags. Similarly, Resident 1 reported being unable to identify staff for the same reason. During an observation, CNA 1 was seen assisting residents without a name tag and admitted to misplacing it without requesting a replacement. The Director of Staff Development confirmed that all staff were expected to wear name tags. Further observations revealed that CNAs 3, 4, and 5 were also not wearing name tags. CNA 3 and CNA 4 both acknowledged forgetting their name tags, while CNA 5 admitted to losing his. The facility's policy and procedure on identification badges, dated 2023, mandates that all employees wear identification badges during work hours, which should be clearly visible and include the employee's first name, last name, and job title. The failure to adhere to this policy led to the deficiency noted in the report.
Failure to Report Abuse Allegations Promptly
Penalty
Summary
The facility failed to implement its abuse policy for two residents when an allegation of abuse was not reported to management by a staff member. A Licensed Vocational Nurse (LVN 1) was informed by another resident that two residents were afraid of a Certified Nursing Assistant (CNA 2) due to alleged physical and verbal abuse. Despite being informed of these allegations, LVN 1 did not report them to management, believing that the resident had already informed the Director of Nursing (DON). LVN 1 intended to discuss the allegations with the DON upon returning to work six days later, acknowledging that she should have reported the allegations immediately. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that staff members are expected to report any allegations of abuse immediately to ensure resident safety. The facility's policy and procedure on abuse, neglect, and exploitation require reporting all alleged violations to the Administrator and relevant authorities within specified timeframes, particularly within two hours if the allegations involve abuse or result in serious bodily injury. The failure to report the allegations promptly had the potential to delay the investigation and place other residents at risk for abuse.
Failure to Notify Physician and Responsible Party of Resident Injury
Penalty
Summary
The facility failed to ensure the Physician and Responsible Party (RP) were notified of an injury for one of three sampled residents. This deficiency was identified during a review of the SBAR dated 4/20/24, which indicated a fall. Further review of the resident's Progress Notes dated 4/21/24 revealed that the resident returned from the emergency room with abrasions to bilateral shins. During an interview and record review with the Director of Nursing (DON), it was confirmed that there was no evidence of the Physician and RP being notified of the abrasions. The facility's policy and procedure titled Notification of Changes, dated 5/1/22, requires informing the resident, consulting with the resident's physician, and notifying the resident's family member or legal representative when there is a change requiring such notification, including accidents resulting in injury.
Call Light Malfunction
Penalty
Summary
The facility failed to ensure that a resident's call light was in working order, which had the potential for staff to be unaware of the resident needing assistance. During an observation in the resident's room, it was noted that pressing the call light button did not activate the call light outside the room or in the hallway. A Certified Nursing Assistant (CNA) confirmed the malfunction and stated that the resident used the call light to request assistance. The Maintenance Director inspected the call light and confirmed it was not working. The facility's policy and procedure indicated that the call light should be functional at all times, but this was not adhered to in this instance.
Failure to Complete Physician-Ordered Wound Care and Monitoring
Penalty
Summary
The facility failed to ensure that monitoring and wound care were completed as ordered by the physician for two residents. For Resident 1, the Order Summary Report (OSR) indicated that the resident's right heel should be monitored for signs and symptoms of worsening or infection every shift for 21 days. However, the Treatment Administration Record (TAR) showed that monitoring was not documented on three occasions. The Treatment Nurse confirmed that if the documentation was not on the TAR, the monitoring was not done. For Resident 2, the OSR included multiple orders for wound care and monitoring of various areas, including the sacral wound, left heel, right heel, left hand, facial flushing, right elbow, and other areas. The TAR indicated that treatment was not done on one occasion, and monitoring was not done on four occasions. The Treatment Nurse and the Director of Nursing both confirmed that treatments and monitoring should have been documented on the TAR, and the lack of documentation indicated that the care was not provided as ordered.
Failure to Notify Physician of Unadministered Medication
Penalty
Summary
The facility failed to notify the physician when a resident was not administered prescribed medications, specifically Bumetanide, which is used to remove excess fluid from the body and is vital for managing congestive heart failure. The Medication Administration Record (MAR) for December 2023 showed that Bumetanide was not given on three consecutive days, and there was no documentation indicating that the physician was informed of this lapse. The Progress Notes indicated that the medication was not administered due to awaiting pharmacy refill and pending delivery. During an interview and record review, the Director of Nursing (DON) confirmed the absence of evidence that the physician was notified about the unadministered medication. The facility's policy and procedure for Medication Administration, dated January 2021, requires that the physician be notified if two consecutive doses of a vital medication are withheld or refused. This oversight had the potential to lead to health complications for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to adhere to its medication administration policy and procedure, resulting in an inaccurate Medication Administration Record (MAR) for one of the sampled residents. The MAR for December 2023 showed that several medications, including Amiodarone, Aspirin, Bumetanide, Carvedilol, and Omeprazole, were not documented as administered on specific dates. The MAR was left blank for the administration times, indicating that these medications were not given to the resident. During an interview and record review, the Director of Nursing (DON) confirmed that the medications were administered on the specified dates but were not documented on the MAR. The facility's policy requires that the individual administering the medication record the administration immediately on the MAR, which was not followed in this instance. This oversight led to an inaccurate MAR for the resident, who was receiving treatment for conditions such as irregular heart rate, coronary artery disease, congestive heart failure, hypertension, and gastroesophageal reflux disease.
Failure to Develop Baseline Care Plan for Wound
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a partial thickness wound to the coccyx area. This deficiency was identified during a review of the resident's progress notes, which indicated the presence of the wound upon admission. During an interview and record review with the Director of Nurses (DON), it was confirmed that there was no documented evidence of a baseline care plan for the wound. The facility's policy and procedure require a baseline care plan to be developed within 48 hours of admission to address the resident's immediate health and safety needs.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to ensure wound care was provided according to physician orders for one of three sampled residents. Resident 1 had an active order for wound care to be performed daily, which included cleansing with a wound cleanser, applying medi honey, and covering with a border gauze. However, a review of the Treatment Administration Record (TAR) revealed that the wound care was not documented as provided on three specific dates. The Director of Nurses confirmed that the wound care was not administered on those dates. The facility's policy and procedure for wound treatment management requires that wound treatments be provided in accordance with physician orders and documented accordingly, which was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 192 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tulare
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tulare Healthcare & Wellness Center, Lp | 0.1 mi | ★★★★★ | 29 | 0 |
| Orchards At Tulare | 0.1 mi | ★★★★★ | 4 | 0 |
| Westgate Gardens Care Center | 6.9 mi | ★★★★★ | 4 | 0 |
| Sequoia Vista | 6.9 mi | ★★★★★ | 12 | 0 |
| Linwood Meadows Care Center | 7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.